THE ANTERIOR CHEST APPROACH FOR OBTAINING FREE OSTEOCUTANEOUS RIB GRAFTS STEPHAN ARIYAN, M.D., ano FREDERICK J. FINSETH, M.D. ‘New Haven, Conn. In recent years, improvements and ex- perience with microvascular techniques have led to the use of free osteocutane- ous rib grafts * for mandibular replace- ments and other repairs. The early re- ports of the use of free rib transplants in dogs stressed the need to use the pos- terior intercostal artery (said to be the endosteal blood supply),' though this approach is difficult, time-consuming, and risky. This paper will present work on ca- daver dissections that led to the develop: ment of a technique for removing free osteocutaneous rib grafts using the an. Poet arcu eet terior approach, and describe its success- ful use in a patient, ANATOMY Several dissections on fresh cadavers were done to study the anatomy of the rib cage. The posterior intercostal ar- teries arise directly from the aorta, and soon give off anterior and posterior rami (Fig. 1), The posterior ramus divides into a muscular branch to the paraspinous muscles, and a spinal branch to the spinal cord and its meninges. The anterior ramus gives off a nutrient vessel to the rib, a mammary branch, and an inter- lnc! Peron Fic. 1, The blood supply to the chest wall. left) The posterior blood supply comes from the aorta, gives branches to the spinal cord, and provides endosteal blood supply to the Fil aswell a6 suppl fo the overiying muscle and skin, right) The anterior blood supply comes ftom the internal mammary artery and provides the perioateal blood supply to the rib, and supply to the overlying muscle and skin. From the Section of Plastic and Reconstructive Surgery of the Yale University School of Medicine. Presented at the Annual Meeting of the American Association of Plastic Surgeons on May 3, 1978 in San Francisco, Calif 676Vol. 62, No. 5 | FREE OSTEOCUTANEOUS RIB GRAFTS costal branch to the muscles of the chi as well as anastomosing with the anterior intercostal artery. The anterior intercostal arteries arise from the internal mammary artery; they supply the rib periosteum, the muscular branches to the intercostal, pectoral, and serratus anterior muscles, and the perfo- rating branches to the overlying sub- cutaneous tissue and skin (Fig. 1). ‘The internal mammary artery de- scends along the internal surface of the anterior part of the rib cage, about one to two cm lateral to the margin of the sternum (Fig. 2). The artery is accom- panied by two internal mammary veins that unite into one vein at about the level of the third costal cartilage. The artery and vein rest posteriorly on the transversus thoracis muscle below the third costal cartilage, which separates these vessels from the parietal pleura. ‘Therefore, composite rib grafts obtained below the 4th rib are easy to dissect 677 while the internal mammary vessels are protected by the tansversus thoracis muscle, DISCUSSION The use of an ordinary bone graft to reconstruct a mandibular segment can fail when there is poor vascularity in the recipient bed as a result of radiation fibrosis or dense scarring from injuries. Island Rib Flaps To get around this problem, Strauch, Bloomberg, and Lewin * demonstrated in 1971 the feasibility of transferring composite rib island flaps to the mandi- ble on the internal mammary vessels in dogs; they proposed a similar procedure in humans.* Soon thereafter, Ketchum, * Editorial note. The reacler will remember that Snyder et al 1 had described a successful human case, with an osteocutaneous podicled flap. one year earlier. Fic. 2. Fresh cadaver dissection of the inside of the anterior chest wall shows that the transversus thoracis muscle separates the internal mammary vessels from the parietal pleura678 Masters, and Robinson * reconstructed a mandible (following a shotgun injury to the face) by using a rib flap pedicled on the internal mammary vessels, However, this necessitated splitting of the sternum, with an open chest approach to the rib and its vessels, Experimental Revascularization of Free Rib Grafts Ostrup and Frederickson * studied the free transfer of composite grafts of rib, muscle, and pleura by microvascular anastomoses of the posterior intercostal artery and vein of the graft to the lingual vessels of the recipient area in dogs. They felt it was imperative that the posterior intercostal vessels be used, because the endosteal nutrient vessel enters the rib near the spine, just beyond the tubercle of the rib. They demonstrated the suc- cessful survival of these free grafts after transfer into recipient beds which had received 5,000 rads of radiation in frac- tionated doses preoperatively.* Subse- quent studies with fluorochrome markers substantiated the survival of the sub- periosteal, the cortical, and the endosteal parts of the rib.* Clinical Transfer of Free Composite Flaps Containing Bone The first clinical transfer of a com- posite flap containing fibula and muscle, with revascularization, was performed by Taylor, Miller, and Ham.’ Then Buncke et al* reported the free transfer of a rib with overlying musculocutaneous tissue (using the posterior chest approach) to the midportion of a tibia. (However, in this same paper they parenthetically re- ported the failure and necrosis of a free osteocutaneous flap from the posterior chest wall to replace a mandibular de- fect in a previously radiated bed.) More recently, Serafin, Villareal-Rios, and Georgiade® reported a free flap PLASTIC & RECONSTRUCTIVE suRGERY, November 1978 transfer of a rib and soft tissues, based on the intercostal vessels dissected pos- teriorly to the aorta. Their first attempt resulted in necrosis of the soft tissues. However, they succeeded in their second attempt, after they had made delaying cisions one week before around the umference of the flap down to and including the fascia over the intercostal muscles. They felt that the delay proce- dure was necessary for the survival of the flap, as they believed that failures were due to vascular insufficiency of the soft tissues, Though they did not report the ischemia time of that graft (stored in ice while they closed the donor site, turned the patient over, and prepared the recipient bed), they did report that subsequent discoloration and edema ne- cessitated the removal 12 hours later of the lateral sutures to release tension. All of the surgeons with some experi- ence with the free transfer of osteocu- taneous rib flaps by microvascular anas- tomoses have stressed the need to use the posterior intercostal artery.'*°%° Their belief is based on anatomical dissections demonstrating that the nutrient vessel arises from the posterior intercostal ar- tery and enters the rib just distal to the tubercle. However, the surgical approach to the posterior intercostal arteries re- quires an extensive dissection through the latissimus dorsi and erector spinae muscles, and these authors stress that care must be taken to prevent damage to the spinal branch "because this could re- sult in a permanent paraplegia? Conversely, we thought the use of the anterior intercostal arteries could in- clade in the stem the internal mammary vessels for the actual anastomoses; they are larger vessels, and this should make for easier anastomoses than either the posterior or the anterior intercostal ar- teries. In addition, the anterior vessels are truncated so they could provide bet-Vol. 62, No. 5 | FREE OSTROCUTANEOUS RIB GRAFTS ter blood flow (through their branches) to the overlying soft tissue and skin— making any delay procedure unneces sary. ‘The big question, of course, has been whether the anterior intercostal supply to only the periosteum of the rib could keep the entire rib alive. A pertinent finding is that of Gothman," who showed in some beautiful microangiographic studies of the rabbit tibia that the inner two-thirds of the tibial cortex are sup- plied by the medullary arteries, while the outer one-third receives its nutrition from the periosteal vessels. In some further work ® he showed that there are fairly numerous anastomoses of fine caliber branches penetrating the whole of the cortex, to communicate between the en- dosteal and periosteal vessels—so_ that after an intramedullary nailing of the tibia (where the endosteal blood supply is extensively damaged) the cortex is then supplied entirely by periosteal branches. ‘We believed that the periosteal blood supply could maintain a rib segment in the absence of the endosteal supply. ‘Therefore, we used an anterior approach technique to obtain an osteocutaneous rib graft in the following case. 679 CASE REPORT ‘A B4yearold male had a resection of a car- cinoma of the anterior floor of his mouth and fa right radical neck dissection in March, 1973. Postoperatively, he was treated with 7,000 rads of external beam therapy. This resulted in ex- tensive osteoradionecrosis of the mandible, and Jed to a mandibulectomy in April, 1974. At. tempts at reconstruction of the mandible with a deltopectoral flap, and using an ordinary bone graft to connect the remaining segments of the rami failed; the result was a persistent orocu- taneous fistula (Fig. 8). In May, 1/7, he was referred to us for reconstruction. OPERATIVE TECHNIQUE The anterior right chest was prepared as a donor area, and a transverse incision was made at the lateral margin of the sternum over the 4th intercostal space (Fig. 4). The perichon- drium was incised and a segment of the 5th chondral cartilage was removed to expose the internal mammary vessels, together with the anterior intercostal branches to the adjacent 5th rib (Fig. 5). Then a 10 x 30 cm area of over- lying skin and soft tissue was outlined and dissected down to the rib (Fig. 6, left). The lateral cutaneous nerve to this segment of skin was freed proximally, and it was left attached to the segment of resected graft (Fig. 6, center) (This nerve was preserved to permit anastomo- sis with the greater auricular nerve upon transfer to the neck.) At this point, the rib was transected at the lateral margin of the flap, and the free composite graft was removed from the Fic. 8, Deformity following extensive mandibulectomy for carcinoma of the floor of the ‘mouth, There was also an orocutaneus fistula below the lower lip.680 PLASTIC & RECONSTRUCTIVE SURGERY, November 1978 Fic. 4. Intraoperative exposure of the 5th rib cartilage (leff) to gain access to the under. lying vessels (right). underlying parietal pleura by blunt disseeffon (Fig. 6, right). With the artery and vein still in continuity, the island circulation to the graft was tested with intravenous fluorescein, and it was found to be intact. With the vessels still intact, the graft was covered with moist pads while the recipient area was prepared. Preparation of Recipient Area Some tissue of the anterior neck, including the undersurface of the orocutancous fistula, was then elevated as a turnover flap to close the fistula and form a new sulcus in the an- terior floor of the mouth (Fig. 7, left). The free margins of the two remnants of the mandibular rami were then dissected free, and the left facial artery and vein were dissected, isolated, and transected. When the facial artery was transected it had a weak blood flow, prob: ably due to the radiation fibrosis and thicken- ing of its wall. Therefore, this vessel was re- sected proximally, segment by segment, until an adequate, brisk, pulsatile blood flow was ob- tained. A segment of the greater auricular nerve was dissected free and prepared for anastomosis to the lateral cutaneous nerve of the rib graft. The Transfer Ac this point, the internal mammary artery and vein of the rib graft were transected, and the graft was put in its new recipient site in the neck. The inner surface of the rib was scored with several transverse cuts (made through the com cave cortex with a power drill) so it could be ent to conform to the curve of a mandible: then the ends of the rib were wired to both mandibular rami with #24 stainless steel wire (Fig. 7, right). (It is unfortunate that the lateral cutaneous nerve was inadvertently avulsed while we scored the rib with the high speed drill, so a sensory nerve anastomosis could not be per- formed.) A strip of fascia lata was then passed sub- cutaneously in the graft, tunneled up through both cheek areas, and cinched up and sutured to the temporalis fascia to provide lower lip support for closure of the mouth.Vol. 62, No. 5 | FREE OSTEOCUTANEOUS RIB GRAFTS 681 Fic. 5. Resection of the 5th cartilage exposes the underlying internal mammary artery and vein (probe, above) and the deeper transversus thoracis muscle (forceps, below) Fic. 6. (left) Dissection of a 10 x 30 cm block of tissue from the chest wall. (center) Freeing the proximal portion of the intact intercostal cutaneous nerve, (right) Freeing the rib from the parietal pleura beneath, End-to-end anastomoses were performed then between the internal mammary and_ facial arteries and veins, under 20% magnification with the operating microscope and using 10-0 nylon sutures (Fig. 8). When the vascular clamps were removed immediate circulation was re- stored to the graft, after a warm ischemia time of one hour and 30 minutes. The skin margins of the graft were sutured to the wound margins in the face. The donor defect on the chest was closed with a transposed deltopectoral flap.682 PLASTIC & RECONSTRUCTIVE SURGERY, November 1978 Fic, 7. (Leff) Reconstruction of the floor of the mouth by a turnover skin flap to close the fistula. (rigit) The rib has been wired in place, and a fascia lata sling has been tunneled across under the lower lip. Fic. 8. (left) Anastomosis of the internal mammary artery (above) to the left facial artery (below). (right) Release of the vascular clamps after anastomoses of both the artery and the RESULT, The entire graft survived without loss of any portion, and the chest defect healed without any sequelae, One month later, the soft tissue of the graft was thinned and revised (Fig. 9), Four months after the transfer, a technetium.99 scan revealed rapid uptake of the radioactive material, inter- preted as viability of the transplanted rib (Fig. 10). To confirm the revascularization, selective arteriograms of the left facial artery were ob- tained at 6 months (after complete and detailed informed consent was obtained from the pa- tient). These arteriograms demonstrated flow in the periosteal arterial branches of significant size (Fig, 11). They also substantiated thatVol. 62, No. 5 | FREE OSTEOCUTANEOUS RIB GRAFTS 683 Fic. 9. Condition after late revision and two months following the composite rib and soft tissue transfer. Fic. 10. A technetium scan at 4 months reveals uptake of radioactive material by the rib. branches from these periosteal vessels _pene- trated the cortex of the rib to provide an endosteal blood supply. Though the vessels in the periosteum and soft tissue are tortuous, the branches within the cortex arc thin and abso- lutely straight until they enter the medullary portion of the rib (Fig. 12). DISCUSSION ‘The technical expertise in microvascu- lar surgery has developed rapidly so that it is becoming a readily available tool in reconstructive surgery. It is now feasible to reconstruct osteocutaneous defects by revascularized free transfers in various anatomical sites. Fic. 11, Selective arteriography of the left facial artery at 6 months. The anterior view shows the hutrient vessels and the periosteal blood vessels (arrows), with a suggestion of dye in the endosteal vessels. Some recent experimental work sug- gests that free periosteal grafts revascular- ized by microvascular anastomoses may form new bone.'* In any event, a con- sistent, readily available, and safe donor site for osteocutaneous or periosteal grafts would make such procedures more ap- pealing to reconstructive surgeons.684 RECONSTRUCTIVE SURGERY, November 1978 Fic. 12, (left) Oblique view of the 6-month arteriogram, demonstrating a straight line vessel (arrows) characteristic of those in the cortex. (right) The same oblique view, after subtraction of fils to better demonstrate the straight line vessel (presumably in the cortex). The anterior approach requires signifi- cantly less dissection, the patient can re- main in the supine position during the entire procedure, the internal mammary vessels are larger donor vessels, and the warm ischemia time is kept to a mini- mum because the donor vessels need not be divided until the recipient bed and its vessels are ready for the transfer. SUMMARY Fresh cadaver dissections indicated that the anterior chest approach for ob- taining a free osteocutaneons rib graft, based on the anterior intercostal vessels, would be feasible. Following this, a mandibular defect in radiated tissue was successfully repaired in one stage by a free osteocutaneous graft with microvascular anastomoses. A 22-cm segment of rib, with overlying muscle and skin measuring 10 X 30 cm, was transferred. Follow-up, with selective arteriography at 6 months, confirmed the belief that the periosteal blood supply alone could support the rib segment. The anterior chest approach, to obtain a free osteocutaneous rib graft, is easier, faster, and safer than the posterior approach, Stephan Ariyan, M.D. Plastic and Reconstructive Surgery Yale University School Medicine 333 Cedar Street New Haven, Conn. 06510 ACKNOWLEDGMENT We thank Dr. Morton G. Glickman for his pains taking arteriographic studies.Vol. 62, No. 5 | FREE OSTEOCUTANEOUS RIB REFERENCES Ostrup, L. ‘T., and Fredrickson, J. Mz Distant transfer of a free, living bone graft by micro vascular anastomoses.” Plast. & Reconstr, Surg.. 54: 274, 1974 Daniel, R. K: Free rib transfer by microvaseu lar anastomoses (Letter to the Eelitor). Plast & Reconstr. Surg.. 59: 787, 197. Strauch, B., Bloomberg, -\. F., and Lewin, M. Lz An experimental approach to mandibular replacement: island vascular composite rib gratis, Brit, J. Plast, Surg., 24: 884, 1071, Ketchum, L.D., Masters, F.W., and Robin son, D, W.: Mandibular reconstruction using a composite rib flap. 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